"Challenges for the Air Safety Investigator and for ISASI"

Remarks by Jim Hall, Chairman
National Transportation Safety Board
before the
International Society of Air Safety Investigators
Boston, Massachusetts, August 24, 1999

Thank you. It is again a pleasure to speak at the annual ISASI international seminar - for the third time in 4 years. I first spoke to you in Seattle in 1995 and then again last year in Barcelona.

One of the reasons I am so pleased to be here is to show my support for ISASI and the goals and objectives for which it stands-"SAFETY THROUGH INVESTIGATION."

In 1995, I was able to wish our distinguished colleague and friend-Mr. Jerome Lederer-happy birthday on his 93rd birthday. Today, I am extremely pleased to see Jerry again, about a month before his 97th birthday.

I have been advised that Jerry is fully Y2K compliant and plans to continue to contribute to making aviation safer well into the 21st century. We are all fortunate to know Jerry Lederer - because of his work the entire world of aviation is safer.

As many of you know, I authorized corporate membership in ISASI for the NTSB more than a year ago to show my support. I also urged that many of our investigators and managers attend this conference to meet and exchange views with all of you.

One of the main reasons I urged such extensive participation by our staff at this seminar is to open and to maintain good communications between all of you and the NTSB. I think both of our organizations will benefit by closer ties.

In preparing for this presentation, I reviewed what I said to you in Seattle and in Barcelona. It was readily apparent that the issues and concerns I raised then are still relevant today. They were:

All of these are important matters for our attention and present difficult and important challenges for air safety investigators. However, there is another most significant challenge facing the air safety investigator - the news media and the 24-hour coverage of events from all over the world. I'll address that shortly.

The job of the air safety investigator continues to be an important element in the efforts to improve on the already excellent worldwide aviation safety record. We all know that the air safety investigator's job is extremely challenging. These challenges include the many round-the-clock hours on duty, the short notice launches to accidents, the environmental and physical hazards at accident sites, the mental and physical stress of the human tragedy involved, and the overwhelming desire to determine the causes in order to take timely accident prevention measures.

How can we help the investigator meet these challenges? One method is to ensure timely and complete communications among all air safety investigators. ISASI, including this forum, provides excellent means to achieve such communications. However, I believe we need more.

There continues to be a lack of adequate notification and reporting of accidents and incidents by the appropriate organizations, both government and industry, on a worldwide basis. Despite the requirements of Annex 13 to the Convention on International Civil Aviation for notification and reporting, compliance with these important requirements is not what it should be.

There needs to be continued and extensive training to enable air safety investigators to do their job. I have made technical training a priority at the Safety Board, and I am committing our agency to an expanded role in providing advanced training for investigators worldwide.

And there needs to be state-of-the-art recorder technology in our modern day aircraft. I read with interest accounts of recent rocket accident investigations that found the causes to involve software problems - in one case, a misplaced decimal point in the computer code. The accidents were attributed to errors in computer code overlooked by engineers and quality assurance personnel. Fortunately, the reason the causes could be determined was the existence of sophisticated data link recording capabilities used for spacecraft.

Would an investigator be able to discover such a problem in the computer code of a crashed civil airliner? Are our investigators trained and qualified to meet such challenges? Are the on-board recording devices crashworthy enough to survive crashes and post-crash fires so we can determine the causes, and are they sophisticated enough to record the parameters we need? In the past few months we lost the data from flight recorders from two transport aircraft accidents-in Turkey and in China. Finding out what happened and why will be most difficult, if not impossible. More importantly, accident prevention measures will not be developed without those data.

There is more we can say about the benefits of international communication and cooperation, but I'd like to shift the focus for a moment to the media and journalism. Modern news is driven by the portability of satellite technology. Everything has become real-time, instantaneous, up-close, and often monotonously over-dramatized in continuing round-the-clock coverage. From the beginning, aviation accidents were big news. Even so, the evolution of journalism over the past fifty years is nowhere more evident than when a large commercial plane crashes. I have a few clips I think will illustrate my point nicely. I want to thank the folks at the Television News Archive at Vanderbilt University and EFX Video of Arlington, Virginia for the clips you are about to see. We will start with two older shots from the fifties and the sixties.

[Newsreel footage of 1956 Grand Canyon mid-air collision and 1963 Trans Canada Airlines accident near Montreal]

The music is something we don't get much of anymore. Perhaps, just as well. Ask yourself, do you recall either report identifying the airline by name? They didn't. Whatever unwritten code was in place, it scrubbed the name of the operator. One didn't even name the aircraft type. But the reporters were anxious to speculate and to report unverified fact - in one case, about a mid air collision, which in fact probably did occur, and in the other, an explosion before impact, which may not have occurred.

Before I begin the next clip, let me acknowledge that we at the Safety Board are not above criticism. While we try to hold to our policy of reporting only factual information, at times we have strayed beyond the boundaries we've set for ourselves.

The remaining clips are not aimed to criticize the specific reporters or organizations depicted here. In many cases, they too are victims of a fast-changing media environment. The competitive forces and the demand for ever-more controversial, startling leads defy the verification procedures that generally used to characterize the reporting of our work.

Now a look at some more recent footage.....The clip we are going to see next was broadcast two days after the crash of ValuJet Flight 592 in May 1996.

[Video clips of ValuJet coverage]

There is enough material in that footage to talk about the rest of the day, so let me just highlight a few points. First, the obvious - this was an extensive in-depth piece two days after the accident, and its authors worked under the clear premise that ValuJet was at fault in Flight 592, and the reporter leaves the strong impression that crew performance may have been the issue. The reporter's claim that the first officer was not medically qualified was wrong. He also leaves the impression that the captain may have had problems controlling her aircraft in an earlier incident, an impression that would not have been factual. Indeed, if she had any recent relevant experience, it was that she had, only recently, safely returned an aircraft to DFW when smoke was detected shortly after takeoff.

Reporters are not the only folks working on insufficient facts and feeling pressured to get before the camera. The challenge for officials from airlines and government - past and present - is not to put themselves into the trap of having to come up with facile answers before the facts are known. And believe me, I know how difficult that can be.

In an ironic coincidence, a Senate hearing on the ValuJet accident took place on July 17, and was a lead story for a while that evening, until our next tragedy pushed it from sight.

[Video clips of TWA flight 800 coverage]

TWA crashed tragically killing all 230 aboard. That's about as much as anybody seems to have gotten right in those headlines and news clips. But it was instructive to watch the press take politicians apart only to expose the susceptibility of their own industry to sensation. Does anyone here think that the Pierre Salinger story should have been the lead on all the major networks that night? It is one thing when a tabloid lives down to its reputation; lately, the lines between traditional journalism, the news/entertainment shows, and outright tabloid exploitation are sometimes too close to call.

We have always had tabloids and the yellow press in this country, but in the past the public didn't confuse them with the mainstream media. They knew what publications were predominantly geared to entertain and which ones were structured to inform. What does it mean that nowadays the public can't tell the difference between the two?

I read an interesting quote from a former Washington bureau chief who was lamenting the changing state of our news coverage. He said, "In the old days, on the first day we would report what happened. On the second day we would tell what the reaction was. On the third day we would analyze what it means. Now, CNN tells you what happened and five minutes later some University professor is telling you what it means. That's the problem. We have to find a way to package it all the first day or we're out of business."

That is the challenge that faces each of you, and every one of us. Every time we embark on a major investigation, we do it under the instantaneous scrutiny of the whole world. This in itself is not a bad thing. The Safety Board prides itself on being an open, public agency, doing the public's business. What is a bad thing is the continuous barrage of misinformation spilled over our airwaves, and to a lesser extent in our newspapers, from a news media that has 24 hours of airtime to fill. Waiting a day for reaction will not do, and waiting two days for analysis would be unheard of. This misinformation distracts the investigative process and brings needless pain to those who have suffered a personal loss in an aviation tragedy.

So, who rushes to fill this vacuum?

To a certain extent, we try to. My agency understands the need for the public to know what happened in a major accident and what is being done about it. While on scene, we hold at least two press briefings a day, not counting appearances on major interview programs. We do this because we believe that there is no greater breeding ground for rumor than the absence of fact. But two press briefings a day account for about one of the 24 hours of that day; there are still 23 hours to fill.

You got a flavor of the result on the tape I showed you. Where once reporters would try to verify stories before putting them on the air, now, we constantly hear what can only be called rumors being spread by what are considered legitimate broadcasters. How many times have you heard a reporter say, "This isn't verified, but...", or "A so-far unsubstantiated report says..." If it isn't verified, if it isn't substantiated, why are they broadcasting it?

This is the journalism of assertion, rather than verification, which was so eloquently described recently in the magazine Brill's Content. We no longer need facts to support what we say, we merely have to assert it as a potential fact and we get it on the air.

One problem, I believe, is that now we don't have the filter of time we once had; every reporter, at least on television, is constantly on deadline. Let me show you one last news clip, a quick account of an accident that occurred on deadline.

[Video clip of Comair coverage, January 9, 1997]

You noticed he said, "Here's what we know." In fact, what they "knew" was wrong. If you were unfortunate enough to have a loved one flying from Detroit to Ohio that night, and you caught that broadcast, you probably went through a needless hell. The plane was not headed for Toledo and it wasn't going to Cincinnati, it had just come from Cincinnati and was headed for Detroit.

As Jonathan Yardley of the Washington Post has noted: "Television news has evolved from a medium for reportage to a stage for melodrama."

Add to this mix another medium to contend with, the Internet. With millions of people having the ability to communicate with each other instantaneously, Mark Twain's words were never so true as they are today: "A lie can travel half way round the world while the truth is putting on its shoes."

All of us have an enhanced role in terms of public accountability. There are instant experts everywhere and we at the Safety Board are often called upon to respond to assertions that have little or no basis in fact. This is the challenge we face, to maintain an honest and constant flow of information while not getting distracted.

Institutions that serve our free society - and that includes government and media, alike - are under constant scrutiny. Just as we in government have to maintain our credibility every day, those in the mainstream media in particular need to work hard to maintain theirs. I would hope that all of us would appreciate the public trust that we hold and be wary of being seduced by the excitement and exposure these tragic events present.

Let me again make it clear. The reasons I showed you these news clips was not to entertain you, nor to embarrass anyone. It was to show you the world in which all future investigations will be conducted.

The media culture in the United States - and increasingly around the world - can impact the institutions we all work for, and profoundly affect the individuals and families that suffer following a major accident.

Regardless what the reasons for this new media culture are, as aviation investigators and individuals interested in the integrity of the process, it is imperative that all institutions determine how best they can fulfill their responsibilities to the public.

As I mentioned earlier, the Safety Board is not immune to straying from the straight path of factual reporting. I'm sure many of you remember times when our spokespeople said things that, on reflection, were either premature or just plain wrong. While we hope these instances are few and far between, we know we have to remain vigilant ourselves. And, we know that the way we have been doing business for the last three decades has to be adjusted to meet today's realities.

We have been meeting with news media and industry representatives to determine how best our information-release procedures can be changed to satisfy today's need for information flow while at the same time preserving the integrity of our investigations. I'll be happy to share those new procedures with you when they are completed in the fall.

Likewise, the Air Transport Association has established an Air Safety Alliance aimed at educating the news media to aviation safety issues, so that when the inevitable story arises they have a firm foundation in the concepts and nomenclature of the industry.

I think your membership can be helpful here. Your society already has a code of ethics that addresses speculation and the public release of information during open investigations; this is commendable. Perhaps you can use your many years of experience in the field of investigations by developing a suggested code of conduct for reporting on aviation tragedies.

Most importantly, what I'm encouraging for you is an active dialog with both print and electronic media from many countries to discuss how we all can better serve the public's interest and the public's right to know after one of these tragedies.

There are many good and professional people in the field of journalism. I know because I work with them almost every day. In the old days, and by that I mean 10 years ago or so, they were the reporters who set the tone for everyone else's coverage. But, no more. The access to technology, the ability to beam a picture from anywhere on earth to everywhere on earth, can outstrip common sense, and in some cases, even common decency.

We would all do well to follow the simple words of Thomas Jefferson that I use as a benchmark for the NTSB. "The care of human life and happiness is the first and only legitimate object of good government." With government, industry and the news media adapting that sentiment to their good works, the public will be well served.

Thank you for giving me the opportunity to share these thoughts with you.


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